Tag Archives: Substance Abuse & Addictions

Substance Abuse & Addictions

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Spinoza was right: Four steps to recovery from addiction

By James Rose August 21, 2018

The 17th-century Dutch philosopher Benedict Spinoza wrote that “when a man is a prey to his emotions, he is not his own master, but lies at the mercy of fortune.” He named this condition “human bondage.”

In my view, there is no greater form of human bondage among us now than drug addiction. Addiction is a form of self-imposed bondage that binds people as firmly as if they were held in chains. People who are addicted are being held in a form of bondage that is rooted in their own emotions.

In my three years of working with people in recovery from addiction, I have seen a clear pattern emerge. Individuals who begin recovery by detoxifying from their drug of choice soon feel a rush of hard emotions. These hard emotions are the ones they have been suppressing with their drug use.

From there, successful recovery follows a few distinct steps:

1) Patients name the emotions they are feeling.

2) They identify the story they have been telling themselves about the people, events or circumstances that are at the root of those hard emotions.

3) They examine the meaning of the story they have been telling themselves and consciously challenge that meaning.

4) They find a way to change the meaning of their story.

Because emotions flow from the stories we tell ourselves, patients in addiction recovery can then begin to change the emotions they feel, including the hard emotions that led to their drug use.

Let’s examine these four steps to recovery in detail.

1) Identify the hard emotions that arise. People vary significantly in their ability to discuss emotions. In general, women tend to be better at expressing their emotions than are men. Among people who abuse substances, both men and women typically struggle with expressing emotions. Not knowing how to handle strong emotions, and needing to numb them out, is often at the root of their use.

I often begin group counseling sessions by asking patients to name various emotions. It is a warm-up exercise to get them thinking about the range of emotions that exist and whether they are feeling them at that moment. Among the emotions frequently listed are loneliness, sadness, abandonment, depression, anger and hurt. Often, I will fill a chalkboard with their emotion words and then ask the participants to pick out a few words that apply to them. By giving patients a broad panoply of emotion words to choose from, they often find it easier to name their own emotions.

2) Identify the people, events or circumstances from which those hard feelings arose. For one young man, it was seeing his father, whom he considered his “rock,” suffer from diabetes and have his foot and part of his leg amputated. This was followed two years later by his father’s death. For a young woman, it was the death of her mother and the simultaneous abandonment by her boyfriend. For another young man, it was the emotional coldness of his father, which compelled him to threaten to commit suicide to get his father’s attention.

A sense of abandonment — and, in particular, abandonment in one form or another by a parent — plays a large part in many people’s addictions. A parent might be physically absent, either through death or divorce, or a parent might be physically present but emotionally absent. This can be the result of a parent who is simply emotionally distant by nature or a parent who is emotionally absent because they are involved in some form of addiction to drugs, alcohol, work, sex, gambling, pornography or other things.

Children by nature model themselves after their parents. Sometimes children are unaware of this modeling behavior. One client hated that his father struggled with alcoholism. So much so that this client had promised himself he would never drink alcohol, and he kept his promise. Instead, he used heroin. He had simply replaced one addiction with another, becoming as emotionally unavailable to others as his father had been to him. One common element among all addictions is that they make a person emotionally unavailable to others around them.

Sometimes I use the analogy of fun-house mirrors — those mirrors they sometimes have at carnivals that distort people’s images. As children, we try to get a clear picture of who we are by the image we see reflected in the eyes of our parents. If a child is fortunate enough to have mature, healthy parents, that child is more likely to gain a reasonably accurate self-image from their parents and have a secure emotional foundation from which to face life.

But if a child’s parents are unhealthy or immature, then the self-image the child receives from those parents is more likely to be distorted or flawed. These children may go through life with the unsettled sense that there is something wrong with them. The grown child then lacks a basis for determining what his or her self-image should be.

That sense of not being able to see oneself clearly can create a lasting pain in a child’s heart, and addictive behaviors are more likely to develop in an effort to numb out that pain. As counselors, our work can involve “reparenting” our clients by providing a clear self-reflection of who they truly are — an image these clients might never have received from their actual parents.

There is also a hidden stigma involved in situations in which children have the opportunity to become better than their parents. Sometimes this stigma is called invisible loyalty. For example, if a child comes from a family where drinking is normal behavior, the child risks breaking a family norm — and thus becoming “better” than his or her parents — by not drinking. That is a step toward independence that not everyone is willing to take.

3) Challenge the story you are telling yourself. Often, the event or circumstance involved in the triggering event creates a terrible blow to the person’s self-esteem. For example, the client whose father walked out on the family when the client was 5 was taught in the most unmistakable terms that he was worthless. The woman whose mother died and whose boyfriend left her shortly thereafter simultaneously suffered both grief and abandonment — abandonment at a moment in her life when she most needed someone she could turn to and trust to help her deal with her grief. The young man who lost his father to diabetes felt cast adrift without the man who had represented stability in his life.

Our emotions follow our narrative. If the stories we tell ourselves are ones of loss, abandonment and aimlessness, our feelings will be ones of worthlessness. It is that feeling of worthlessness at the core of our being that is often at the root of addiction. Addiction is a way of trying to numb out those unbearable feelings. If our narrative tells us that all is lost, then there is nothing much to do but to numb out our pain and drag ourselves through life as best we can.

Our feelings are predictions of what to expect, based on our past experience. If our past experience has been full of sorrow and loss, we will come to expect more sorrow and loss in our lives. We will approach the potential of something joyful happening in our lives with dread, lacing it with the expectation that, sooner or later, things will turn out badly. If close relationships turn into abandonment and loss, we might create self-fulfilling expectations by not entering into new relationships with openness.

And yet, it is human nature to want to have close relationships. One young man with whom I worked desperately wanted to feel some sort of emotional connection with his father. To all appearances, his father was a good man and a good father, but he was incapable of showing warmth and caring to his son on an emotional level. The son’s drug use was an attempt to self-medicate the pain he felt at the lack of that important connection in his life.

It reached a point where the son called his father and said he had a knife in his hands and was ready to slit his wrists because he was so desperate for his father to show some level of care and concern for him. The father responded; the son did not commit suicide. He told his father of his drug use, and the son agreed to go into recovery. The son had received a message of worthlessness from his father, and he found that message too painful to live with. He forced his father’s hand to show caring.

In recovery, the young man gained an understanding of how deeply he felt the sense of emotional abandonment by his father. Once he gained an understanding of that emotion, he was ready to pursue the fourth step.

4) Change the way you tell your story. For that young man, recovery meant telling his story differently. Instead of telling himself that his father’s coldness meant he was worthless, he came to understand that his father’s coldness was his father’s nature — the product of his father’s own difficult upbringing. The son learned that he was capable of finding the sort of emotional connection he craved with his mother, his siblings, his friends and his new companions in Alcoholics Anonymous (AA).

He came to accept that he would never change his father, but he learned that he could change himself so that he could find the emotional gratification he longed for from others. He had previously believed that he needed to be like his father — cold and emotionless. Once he changed his story and gave himself permission to truly feel the emotions he was experiencing, he could share those feelings with others and find the sort of emotional connections that he craved. Once those emotional longings were satisfied, his need to numb out his more painful emotions evaporated.

Changing one’s story is fundamentally an act of building self-esteem. Self-esteem is built in a number of ways. It comes from allowing oneself to feel one’s emotions, from avoiding all-or-nothing thinking and from recognizing that life events most often consist of shades of gray. Finding the strength to express one’s true self among others, and to experience that self as different from other people and to develop enough detachment to become comfortable with those differences, is also essential.

For some people, and particularly those who had difficulty with their parents while growing up, spirituality may provide the context for seeing themselves differently. This is the concept behind the step in AA to surrender to a higher power, however that higher power may be understood. Seeing oneself as a child of God may provide a corrective lens for those who grew up with the fun-house mirrors and were never able to gain a true picture of themselves through the eyes of their parents.

I once spoke at a Christian-based recovery center where I offered that sort of corrective vision to the patients by slightly changing the word order of a familiar Scripture reading. I told the audience, “If you want to know who you are, consider these words from the Gospel of Matthew. ‘You are blessed, you who are poor in spirit, because yours is the kingdom of heaven. You are blessed who mourn, for you shall be comforted. You are blessed who are meek, for you shall inherit the earth,’” and so on through the remaining Beatitudes. And then I said, “You are a child of God, because why else would Jesus have taught us to pray to God as ‘Our Father?’”

Learning to see oneself differently, and changing one’s story in a way that builds self-esteem, is the fundamental act of recovery. Guiding patients through the growth of creating a healthy sense of self-esteem is at the core of my work as a counselor. People are not only recovering from the habit of substance abuse. They are recovering their lost selves.

Spinoza wrote, “The more clearly you understand yourself and your emotions, the more you become a lover of what is.” Examining emotions with patients and helping them to see themselves as they truly are is the royal road to helping those in recovery. It is the path that leads them to self-knowledge and self-esteem. Ultimately, it is the path out of the trap of human bondage.

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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Read more by James Rose, from the Counseling Today archives: “Stepping into recovery

 

Related reading, also from Counseling Today: “Grief, loss and substance abuse

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Addicted to sex?

By Amanda L. Giordano and Craig S. Cashwell August 7, 2018

Sex and sexuality are necessary, healthy and, arguably, sacred aspects of the human experience. What happens, though, when sex is used not to enhance intimacy and connection with others but, rather, becomes out of control? What happens when a person describes a clear set of personal values around sexual behavior yet consistently crosses his or her own boundaries and compromises personal sexual values? What happens when a person continues a pattern of sexual behavior despite detrimental consequences? Can a person be addicted to sex?

Although most forms of sexual expression are healthy, the sex addiction model posits that some individuals may develop compulsive, dependent relationships with sex. Critics of the sex addiction model suggest that the addiction label pathologizes nonnormative sexual behaviors (e.g., fetish, kink), yet true proponents of the model do not claim to define morally appropriate forms or frequencies of sexual acts. The focus, rather, is on one’s relationship with sex.

Just because a sexual behavior violates an individual’s personal values, religious or spiritual beliefs, or societal norms does not make it an addiction. Instead, sex addiction has specific defining characteristics:

  • Loss of control
  • Continued engagement despite negative consequences
  • Mental preoccupation or cravings

Thus, rather than being sex-negative, advocates of the sex addiction model work to identify those who are unable to control their sexual behavior, are experiencing distressing outcomes and are mentally preoccupied or craving sex. Once sex addiction is determined, individuals then can get the treatment and support they need to establish healthy sexuality. 

A topic for debate

The notion that sex can be addictive still is debated among mental health professionals. Instead of addiction, alternative explanations for problematic sexual behaviors include impulse-control issues, obsessive-compulsive disorder, neuroticism, learned behavior, a form of sensation seeking, internalized sex-negative messages or manifestations of a mental health issue such as bipolar disorder.

The addiction model, however, purports that the primary issue is an out-of-control relationship with sex resulting from changes in chemical messengers in the brain. Specifically, naturally reinforced behaviors, such as eating and sex, are linked to the release of neurotransmitters (i.e., dopamine) related to pleasure and reinforcement. A naturally rewarding behavior such as sex can become a supernormal stimulus leading to dysregulation in the dopaminergic system. The resulting neuroadaptations affect reward, memory, attention and motivation. Thus, from an addiction model perspective, sex can hijack the natural functioning of the reward pathway in some individuals, leading to addictive behavior.

The sex addiction model contends that in addition to being positively reinforcing through the release of dopamine and other neurotransmitters, sex can be negatively reinforcing. Over time, sex can become addictive when it is used as the primary or, sometimes, sole method of regulating undesirable emotions. In other words, sexual behavior can be negatively reinforcing when it functions as an avoidance strategy and is used to escape emotional pain. In a negative feedback loop, however, the individual often feels shame as a result of his or her out-of-control sexual behavior. Paradoxically, this shame may become part of the undesirable emotions that the person then strives to regulate through sexual acts. From an attachment perspective, it is likely that these individuals never learned to coregulate emotionally and, instead, try to autoregulate emotions.

Scholars who primarily emphasize the negative reinforcement of sexual behavior often argue for terminology other than sex addiction, such as compulsive behavior or hypersexuality. However, the fact that sex provides both negative reinforcement (i.e., escape) and positive reinforcement (i.e., pleasure) seems to give credence to the addiction model.

Although controversy remains, the mental health field is steadily embracing the notion that behaviors can become addictive. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the diagnosis for gambling disorder in a chapter titled “Substance Use and Addictive Disorders.” In addition, internet gaming disorder and nonsuicidal self-injury (which some conceptualize as a behavioral addiction) were included in Section III as conditions in need of further study.

A diagnosis of hypersexual disorder was considered for the DSM-5 but ultimately was not included. The American Society of Addiction Medicine, however, revised its official definition of addiction to include both chemicals and naturally reinforcing behaviors. Furthermore, within the World Health Organization, the Working Group on Obsessive-Compulsive and Related Disorders for the 11th version of the International Classification of Diseases has recommended a diagnosis of compulsive sexual behavior. The organization determined the need for additional research to classify sexual behavior as addictive but clearly recognizes that out-of-control sexual behavior is a public health issue.

In addition, the recent surge of public concern related to pornography use and related erectile dysfunction among relatively young men (as evidenced by high traffic on websites dedicated to helping individuals “reboot” or discontinue use of pornography) has contributed to the influx of neuroimaging studies exploring addiction to pornography. Researchers have confirmed that the same regions of the brain activated by drug stimuli also are activated by online sexual stimuli and that addictive sexual behavior may be associated with decreased gray matter and diminished connectivity in the brain.

Types of sex addiction

Scholars conceptualize two types of sex addiction. The profile for the classic type includes early attachment wounds, family-of-origin issues and trauma histories, culminating in insecure attachment strategies in adulthood. Research shows a clear link between problematic sexual behavior and insecure attachment styles, and the majority of individuals in treatment for sex addiction have experienced trauma. For individuals with classic sex addiction, their sexual behavior may have been a primary means to fulfill attachment needs or escape emotional pain. Over time, however, the behavior became compulsive and out of control as the natural longing for sex became a need and then an addiction. 

Recently, a second contemporary type of sex addiction has been identified among individuals without the classic profile of trauma or attachment wounds. Instead, the contemporary type emerges as a result of chronic, excessive exposure to sexual stimuli, especially in the form of pornography or cybersex, made more readily available when the internet became ubiquitous. Sex researcher Alvin Cooper referred to cybersex as a triple-A engine, offering affordability, anonymity and accessibility to users.

Online sexual images and videos are pervasive, and current estimates suggest that the average age of first exposure to pornography is 11. This initial exposure is often accidental on the part of the child, with pornography sites known to purchase domain names of commonly misspelled children’s websites (referred to as cybersquatting). Over time, however, pornography becomes a supernormal stimulus reshaping the brain by repetitive experiences of pleasure associated with online sexual images. The brain responds to this hyperactivity in the reward pathway by decreasing natural dopamine production and receptors. Consequently, with decreased natural dopamine production, those with sex addiction may feel mildly depressed at baseline, inducing cravings for sexual behavior to alleviate the negative mood. Thus, whether classic or contemporary, sex addiction leads to changes in brain circuitry, which, in turn, perpetuates the addictive cycle.

The nature of sex addiction

Among individuals for whom sex has become addictive, the condition is all-consuming. When those with sex addiction are not engaging in sexual behaviors (acting out), they likely are thinking about them (fantasy and mental preoccupation), getting ready for them (preparation and ritualization) or recovering from the consequences (physically and emotionally).

Sensitization caused by neuroadaptations may lead individuals to seek novel or more intense sexual stimuli to achieve the desired effect (otherwise known as tolerance). For example, an individual may shift from nonviolent to violent pornography or change from streaming cybersex to partnered anonymous sex. Those with sex addiction begin to live a double life as they hide their out-of-control sexual behaviors from others, withdraw and isolate. Furthermore, many people with sex addiction lose sexual interest in their romantic partners and experience sexual dysfunction because of classic conditioning in which arousal is paired with alternative stimuli such as a computer. The addiction affects the individual physically, psychologically, spiritually, relationally and emotionally. Although sex addiction begins to control these individuals’ lives, they often are reluctant to tell anyone about their experience because of intense feelings of shame and self-loathing.

Addictive sexual behavior can manifest in a variety of ways, from compulsive masturbation, anonymous sex and prostitution to compulsive sexual relationships, voyeurism or rape. Indeed, some sexual acting-out behaviors can cross the legal line and fall into the realm of sexual offenses, but the majority of those with sex addiction do not offend; rather, they engage in legal forms of compulsive sexual behavior.

Sex offenders generally have distinct profiles from sex-addicted nonoffenders. Specifically, sex offenders are more impulsive; engage in more intrusive behaviors; respond to offenses with hatred, anger and entitlement; and have low remorse. This profile differs from the progressive trajectory of sex addiction that tends to include more frequent, yet less intrusive, acting out; triggers shame, despair and powerlessness; and is met with high remorse. When sexual acting-out behaviors cross the line of legal offense, those who are sexually addicted are legally responsible for the consequences of their actions despite having an addiction (much like someone with alcohol addiction who injures another person while driving under the influence).

Although individuals with addiction are not responsible for “giving themselves” sex addiction, they are responsible for their recovery through seeking help and working a treatment program. Increasing public awareness about sex addiction can help promote early access to professional treatment, with the hope being that this step will aid in avoiding decades of negative consequences both for individuals with sex addiction and for others who may be affected.

Clinical considerations

Given that sex addiction can include myriad sexual behaviors, it is important for clinicians to assess and screen appropriately. Most sex addiction emerges in late adolescence and young adulthood, so school counselors and community clinicians working with young clients can provide early intervention by regularly screening for sex addiction. Counselors are encouraged to broach the subject of sex in counseling and explore clients’ relationships with their sexual activities, such as masturbating, sexting, hooking up, using pornography, engaging in cybersex, using sexual apps and engaging in compulsive sexual relationships.

Despite the fact that sex addiction emerges early, most individuals do not seek professional treatment until later in life as a result of experiencing often extreme negative consequences (i.e., “hitting rock bottom”). Accordingly, all clinicians should be screening for a loss of control over sexual behaviors, continued engagement in sexual behaviors despite negative consequences, and mental preoccupation or cravings. Along with informal screening and exploration, many formal assessments for sexual compulsivity and addiction exist, including the Sexual Addiction Screening Test, the Sexual Compulsivity Scale and the Sexual Dependency Inventory. The use of these instruments can help clinicians better understand their clients and coconstruct appropriate treatment goals.

Once counselors identify the presence of sex addiction, they have many tools and treatment programs to assist in helping clients reach long-term recovery. Unlike recovery from chemical addictions, the goal of sex addiction treatment is not abstinence from all sexual acts, but rather the development of healthy sexuality. It is the compulsive, detrimental sexual behavior that counselors and clients work to eradicate.

To help clarify recovery from sex addiction, many clinicians and 12-step recovery programs (such as Sex Addicts Anonymous) use the three-circles activity. With a sponsor or counselor, those with sex addiction draw three concentric circles. In the innermost circle, the client lists all unhealthy sexual behaviors that have led to negative consequences and over which the individual has lost control. These are the behaviors from which the client is choosing to abstain.

In the middle circle, the client lists behaviors that may lead to sexual acting out. Identifying middle-circle behaviors is important from a neurological perspective. The amygdala is responsible for emotional memory; thus, it remembers stimuli associated with the experience of pleasure. After years of sex addiction, individuals likely have associated specific locations, sounds, sights, smells and actions with sexual pleasure. The middle circle, therefore, includes any stimuli, such as excessive fantasizing, cruising or sexually objectifying others, that may trigger the amygdala and lead to sexual craving.

Finally, the client uses the outermost circle to identify healthy behaviors that will support the individual’s recovery. These behaviors might include participating in 12-step groups, engaging in counseling, fostering spiritual practices, exercising, eating healthy, keeping home and work spaces nonchaotic, spending time doing recreational activities and increasing healthy social support.

Many counseling approaches and interventions, including cognitive-behavioral approaches, psychodynamic approaches, acceptance and commitment therapy, motivational interviewing, art therapy, group counseling, couple and family counseling, and even psychopharmacology, are appropriate for work with sex addiction. It is important to note that recovery from sex addiction often spans years rather than months. Clients, family members and partners may erroneously believe that recovery occurs within a matter of weeks and can become disheartened when initial attempts to change behavior are unsuccessful. Providing psychoeducation about the neurobiology of sex addiction can offer a more accurate perspective and create realistic expectations. Clients can find hope in the fact that, in time, the brain can heal and resolve dysregulation in the reward circuitry. This healing process takes time, however, and the completion of specific tasks such as those outlined in Patrick Carnes’ 30 tasks of recovery.

Additionally, sex addiction may not be the only concern addressed in treatment. Given the common mechanisms underlying addiction, it is not surprising that coaddictions to gambling, food, gaming, the internet or substances often exist among those with sex addiction. Furthermore, research supports the prevalence of comorbid mental health problems, including bipolar disorder, major depressive disorder and attention-deficit/hyperactivity disorder, among those with sex addiction. Finally, a trauma-informed perspective may be necessary to help clients resolve trauma to improve emotion regulation.

Clinicians should take an integrated approach to address all addictive and mental health concerns in treatment. Integrated care may be more complex than addressing one concern at a time, but diverse treatment teams, supplemental or adjunct resources, and holistic recovery plans can best help clients reach long-term health and wholeness.

Advocating for clients

One of the most necessary forms of advocacy for this population is increased awareness related to sex addiction. During the Masters Tournament in 2010, roughly six months after the story broke concerning Tiger Woods’ sexual behavior and treatment for sex addiction, someone flew a plane over the Augusta National Golf Club with a banner reading, “Sex addict? Yeah. Right. Sure. Me too.”

It is inappropriate for anyone outside of Woods’ personal and professional circle to try to determine a clinical diagnosis for his case, but the plane and banner reflect a popular public sentiment: Sex addiction is not real. Advocates can work to increase public knowledge relating to sex addiction and dispense critical research about the condition.

Additionally, mental health professionals can take several practical steps to advocate for clients who are sexually addicted. Currently, many counseling centers do not include information about sex addiction on their websites or relevant items on their intake forms. This lack of acknowledgment may inadvertently communicate to clients that sex addiction is not an appropriate topic for counseling. Thus, one of the simplest forms of advocacy is to include the experience of compulsive sexual behavior on websites, advertisements and client intake forms.

Another important advocacy effort is to acknowledge that individuals of all genders can have sex addiction. Specifically, when community groups, media spokespeople or well-meaning educators leave women out of the conversation about addiction to sex or pornography, they add a layer of stigma for these individuals. Although prevalence rates may differ among genders (about 1 in 7 of those with sex addiction are women), it does not discount the salience of sex addiction among female populations.

Finally, the most recent standards of the Council for Accreditation of Counseling and Related Educational Programs require educators to teach students about theory and etiology of addictive behaviors. Therefore, counselor training programs can advocate for future clients by infusing relevant, up-to-date information regarding sex (and other behavioral) addictions in the counseling curriculum.

Conclusion

Much work is needed to decrease the stigma and shame associated with sex addiction. Although stigma exists with any addiction, it seems particularly poignant with regard to compulsive sexual behavior. In the cycle of sex addiction, shame serves as both a precursor and a consequence of sexual acting out. Raising public awareness regarding the nature of sex addiction can help combat this shame.

Rather than conceptualizing compulsive sexuality as a moral failing, the addiction model provides a framework to empower clients to manage their condition while offering effective tools for recovery. Controversy may always exist regarding the conceptualization of sex addiction, but it is imperative to continue the conversation, increase empirical evidence and engage in advocacy efforts to serve and support this population.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Amanda L. Giordano is an assistant professor at the University of Georgia. A licensed professional counselor, she specializes in addictions counseling and multiculturalism. Giordano serves on the executive board for the Association for Spiritual, Ethical and Religious Values in Counseling and the editorial review boards for the Journal of Addictions & Offender Counseling and Counseling and Values. Contact her at amandaleegiordano@gmail.com.

Craig S. Cashwell, a professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, is an American Counseling Association fellow. Additionally, he maintains a part-time private practice focusing on couple counseling and addictions counseling. He serves as editor-in-chief of Counseling and Values.

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Stepping into recovery

By James Rose June 13, 2018

After many years of working as an accountant, I decided to enter counseling as a profession in my “retirement” years. After four years in graduate school, including two years of clinical work at an addictions recovery center, I began my new professional career this past January. Here is how it began.

 

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It was my third day as the evening counselor at Ashley Addiction Services. A clinical aide called me and said, “We have a patient here who wants to leave now. He’s calling his girlfriend to get a ride, and he is looking for someone to punch so he can get kicked out. Would you come down?”

The patient was a young man I had met during my training period the prior week. “You look stressed,” I said.

“Of course I’m stressed!” he screamed back.

I coaxed him out of the clinical aide’s office to a quiet place where we could talk. He told me he was on the withdrawal drug Suboxone. He wanted to go out and get high, then quickly get enrolled in another facility so he wouldn’t disappoint his mother.

“Your mother’s opinion is important to you,” I said.

“Of course,” he said.

“What about your dad?” I asked.

“He’s dead,” he told me.

I asked him to tell me more. He had been using for seven years. This was his fourth stay in a recovery facility.

“What happened seven years ago?” I asked.

“Nothing,” he said.

“When did your dad die?” I asked, following a hunch that there might be a link.

“Five years ago,” he said.

No link, I thought.

I had been working in addictions recovery for two and a half years at that point. I spent most of my life as an accountant, working in grants administration at various universities. At age 58, I had a near-fatal heart attack, and during my recovery, I knew that I had to change course in my life. Counseling had always fascinated me, and I had been in and out of therapy myself for about seven years. I made the decision six months after the heart attack to make a major course change in my life and study counseling. I enrolled in the pastoral counseling program at Loyola University Maryland, the same school where I had earned a Master of Business Administration 26 years earlier.

As part of my counselor training, I had worked as an addictions counselor at the Westminster Rescue Mission. I remembered a story about another patient I had worked with there who reminded me of my current patient. I shared that story with my current patient, explaining that my former patient’s parents divorced when he was 5. His dad lived only a few blocks away after the divorce, but he rarely saw his dad. Sometimes his father would tell him he would take him fishing on a Saturday morning, so this young boy would get up early, get dressed, assemble his gear and wait all day at the living room window for his dad to come. His father never came.

My former patient started shooting heroin when he was 18 and continued to do so for the next 24 years. After working with this patient for a year, he said to me, “Until we talked, I never understood the connection between what my father did and my addiction.”

Something in this story seemed to resonate with my current patient. So I asked him again, “What happened seven years ago?”

“That was the year my dad got sick,” he said. “He got diabetes and had to have his foot amputated. He was my rock.”

And then it hit him: the link between his dad’s sickness and death, and his own addictive behavior. He jumped out of his chair, threw his arms around me and shouted, “You just saved my life!”

I breathed a sigh of relief. It was a heady moment for me. We both knew an important bridge had been crossed. We talked a little while longer, then went for a quiet walk outside.

 

An epidemic of loneliness

People talk of the tragedy of the opioid epidemic. And the tragedy is painfully real. One of my patients lost two friends during his first weekend in recovery, and he believed that if he had not come in for help, he too would be dead. Another patient found his best friend dead from the dope he had shared with him. A third patient stood before the entire patient community and told us that he had lost 42 friends to overdoses in one year, and he knew that if he did not come in for help, he might well be next.

And yet from my perspective of working with people in addiction, the opioid epidemic masks a deeper epidemic. The epidemic I see every day is an epidemic of loneliness.

It is so ironic. We have never been more connected. We have cell phones, email and FaceTime. We can meet anyone, anytime, anywhere. The world I live in today reminds me of the futuristic world I saw pictured in science fiction comic books when I was a kid. And yet, rather than being more connected, we seem more distant from each other than ever before.

I believe that we all need a deep sense of connection with other people in our lives. Emotional connection is an essential part of being human.

People in recovery are in a state of inner conflict. They simultaneously want to recover and stop abusing drugs and alcohol, while at the same time they have cravings to continue to use. When they stop using, once they get through the painful physical symptoms of detoxifying, the painful emotions that led them to use in the first place tend to rise to the surface. Often, there is a painful event or painful circumstance in their lives that caused them to use in the first place.

Substance abuse is often a coping strategy, a way of easing pain, and very often it is some painful event that triggered their addiction. Substance abuse serves a function in their lives; it reduces their pain enough to enable them to cope and carry on with their lives. In that way, it is similar to taking a pill to get rid of a headache. Of course, the circumstances are far more drastic.

I asked one user why he used heroin, and he said it was better than committing suicide. It was hard for me to argue with his logic. From his perspective, heroin use had the positive aspect of keeping him alive, of keeping him from killing himself by his own hand. That is part of the reason that it is so hard for people to give up their addiction. It serves the positive function in their lives of keeping them alive, allowing them to continue to function, in spite of their pain. It numbs out their pain, however temporarily.

Unfortunately, in numbing out their pain, it numbs out all of their other emotions as well. This is why it is nearly impossible to have a meaningful relationship with someone who is addicted to a substance. Meaningful relationships require an emotional connection. How can one have a meaningful connection with someone whose emotions are chronically numbed out?

 

Breaking the cycle

The damage of addiction spreads out like the ripples in a pond, far beyond the individual who is addicted, to affect all the other people in that individual’s life — friends, family members, co-workers. Children of parents who are addicted grow up with parents who are emotionally unavailable. These children’s lives are shaped by the experience of emotional unavailability, and so the cycle continues.

Breaking that cycle of emotional absence is at the heart of the work I do. When patients stop using, the emotional pain that led them to use in the first place reemerges, and they often are as unequipped to deal with that pain in the present as they were in the past. As their counselor, I help patients to identify past trauma and try to find a new perspective through which to see it.

One way of looking at emotions is to think of them as predictions of what is about to come. If you enter a house filled with the aroma of freshly baked chocolate cookies, you might find your mouth starting to salivate and your stomach starting to rumble — physical signs that your body is preparing for you to eat something yummy. A sudden scream in the night might make your body straighten, your muscles tense, your eyes widen and your ears perk up — all signs that your body has gone into a high state of alert for possible danger, usually accompanied by a sharp rush of adrenalin to be ready for fight or flight. Again, these are the physical signs of anticipation of and preparation for predicted danger.

Emotional pain evokes different bodily reactions. We may feel a loss of appetite, a heaviness of heart and a wish to isolate. The triggers for emotional pain may be less obvious to a person than is the smell of cookies or a scream in the night, but they are certainly quite real to the person experiencing them. And the pain can be overwhelming.

This is where substance abuse comes into play. Often, emotional pain comes about when a person has lost someone with whom they had an important emotional connection in their life, and that emotional connection has been broken. If a parent has died or moved away, a loved one has betrayed you or a traumatic event such as a rape or murder has occurred, there is no way to undo the event. The pain of such events can be overwhelming.

Drink or drugs can provide a means of easing the pain enough that the suffering person can get on with their lives, but they cannot undo the event. Many people find solace over time and find ways to cope with the pain without resorting to drink or drugs; however, many do not. Because drugs numb the pain without addressing the loss, a person remains stuck within the loss, and so the need for the drug endures.

The damaging paradox of a person who uses drugs to deal with the loss of emotional connection is that drugs eliminate the possibility of creating new emotional connections, which are the very thing the person needs to heal. Drugs numb out all emotions — both the painful and the joyful ones — and without the ability to feel the full range of emotions, any new, real emotional connections are impossible to create.

 

Searching for ‘meaning’

Being with a person in the initial stages of recovery from substance abuse is an awesome experience. As a counselor, I face them in that moment of transition in their life. I know I cannot fix or heal anybody. The thing I can do is to be present with them, offering what guidance and presence I can as I try to help them find healing within themselves.

Often, that is a matter of helping them name and identify those hard emotions that arise within them — the ones that led to substance use in the first place. Once the emotions are identified, then we look for the event or the circumstance in their life that brought that emotion into play. This is the moment when the hard stories come out, the stories of heartache and loss. And then it is a matter of looking at the meaning those stories have had in their lives.

It is the meaning we place on our stories that give them their emotional charge. A child whose parents divorced and whose father moved away might, as a child, believe in some unnamed way that they are worthless. After all, dad delivered the message, in the most obvious way possible, that they were not worth sticking around for. I have known many people struggling with addiction who had just that circumstance in their lives, and that sense of worthlessness was at the root of their addiction.

In this work, we can look at stories like that and change the meaning. The meaning might be that dad was a troubled man. It might be that dad and mom had a bad marriage and their breakup was necessary. It might be that dad had to go away on a job or for military service. By reframing the story, we can change the meaning, and when we change the meaning, the emotions that accompanied that story can change.

This was the case for the young man whose story I shared at the beginning of this article. For him, the meaning of his dad’s sickness and death was that he was losing his rock, and there would be no one there to give him guidance. His story changed to dad was sick and died through no fault of his own, nor by his father’s choice, and now he would have to find his own guidance. In changing the meaning of his story, his emotions changed, and his need to numb out his painful emotions with drugs gradually evaporated.

 

Being present

So, at the heart of my work is the aim of being present with another person so that they can learn to be emotionally present themselves. One of my favorite outcomes was when a patient told me about his 17-year-old daughter. She was the rock of their family, a straight-A student who was always reliable and dependable, emotionally calm and stable.

She came to visit her father a few weeks after he had entered recovery. He told me he could not believe what had happened. His strong, calm and rational daughter had broken down in tears in front of him. I said, “She was emotionally present with you.” After a moment, I asked, “Do you understand why?”

He looked baffled and said, “No.”

I said, “For the first time since she was a little girl, she could sense that you were emotionally present for her, no longer drunk or high, but really right there with her. She felt it, and so she, for the first time in years, was able to be emotionally present with you. That is why she cried.”

My final meeting with the young man whose father had died of diabetes was the night before he completed the program. He told me that he was planning to move back home where he could help his mother. He expected he would be able to go back to work at his job in a restaurant, and he planned to attend school in the fall. I asked what he would study, and he said he was interested in psychology. He said he was thinking of becoming a counselor, which would further motivate him to stay on his path of recovery.

I saw him again the night he finished the program. I was thinking of the years I had spent in grad school — the books I had read, the papers I had written, the checks I wrote and all the time I had invested. And in a moment, it was all worthwhile when he threw his arms around me and said, “Thank you.”

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The opioid crisis and a wounded counselor’s heart

By Antoinette D’Angelo (pseudonym) May 14, 2018

[Editor’s note: Because of the personal nature of the narrative, the author is using a pseudonym.]

 

“Welcome to the club!” This greeting, typically extended to new members, often implies certain advantages, discounts and perks. However, the club my husband and I unwittingly have joined is based on an experience I would not wish on my worst enemy.

We received “the phone call” — the one every parent dreads in their wildest nightmares — at 2:30 in the morning in mid-February. It was the police station calling to tell us that our son had overdosed. He was alive, barely, but they had found him just in time.

A tumult of thoughts raced through my mind. Our son lives 2,600 miles away. Could it be a mistake? Were they sure it was our son? He wasn’t supposed to be in that city. What is happening?

As I write this, I know similar words must have been said or written a million times over by so many other heartbroken parents. In truth, there is nothing new to read here. Yet, it is my son I am writing about, my “kid” (now in his 30s). It is my same son whom I desperately worried may not live when I went into labor at six months gestation. It is my child whom the OB-GYN gave only a 10 percent chance to make it. It is my child who did make it, who went on to do great in school, who had tons of friends, who graduated from college, who got married and had a wonderful job. It is my kid who loved cutting down Christmas trees when he was little, swam like a fish and played soccer until his feet ached. It is my child who loved our annual summer trips all across the country to see major attractions and visit dozens of national parks. And it is my son whom the police were now telling us had almost died of an opioid overdose.

I write this story partly for the cathartic release it provides. Our family has cried more tears over the past few months than we could have previously imagined possible. Perhaps more important though is this: The ultimate irony of this situation is that I am a licensed mental health counselor, a licensed addiction counselor and a master addiction counselor. I am an assistant professor of counselor education and teach courses in addiction and treatment. I “know” so very much — maybe even too much on paper — about this disease of addiction, while simultaneously finding that I know so very little.

 

A quest for treatment

A few hours later, we raced to the airport, my husband catching the first available flight to the East Coast. We decided that once my husband got more information, I would fly out. Unfortunately, his plane was delayed, he missed his connecting flight and he ended up arriving after midnight. With no “new” news about our son, the hours ticked by excruciatingly slow.

The next morning, my husband went to see our son in jail — the words still seem incredulously stark written here. They brought our son out in a wheelchair. He was retching violently, trembling uncontrollably and could barely speak. My dear, sweet, gentle husband wept because he thought our son, who was in full-blown detox, was going to die. My husband and son could talk with each other only through a television screen. After 10 minutes, they took our son away.

I called the jail shortly thereafter and pleaded to find out what was happening. The response was that they weren’t allowed to tell me. Many hours later, I was routed to an “angel” sergeant who explained the jail’s “detox protocol” — they give the inmates Tylenol and a pill for nausea, but the inmates throw that up immediately.

Our son was in sheer agony, and we had never felt so utterly helpless in our entire lives. We could not even get a message to him. The whole experience shook us to our cores, and we felt nearly incapacitated by immobilizing grief.

My husband had his “one allotted visit” for the week, which was on Saturday, meaning that the next visit couldn’t be until Monday. We were distraught with worry about our son’s condition but weren’t allowed any additional information. We contacted an attorney in the area whom we had worked with previously years prior. Blessedly, he took on our son’s case but was likewise unable to find out anything over the weekend — and Monday was a holiday. Our agony continued, piercing our souls.

Tuesday was the bond hearing. Our son had been charged with two felonies and two misdemeanors. Our attorney spoke on our behalf. Amazingly, our son was released from jail in our recognizance, as long as he agreed to go directly into treatment.

The next several days were a blur-filled nightmare that involved navigating the quagmire of insurance situations. We found that because our son was “five days sober,” no detox unit would take him, reasoning that he was not in quite desperate enough straits at that point. No residential treatment center would take him; he didn’t qualify for Affordable Care Act insurance because he had lost his job. He couldn’t get on Medicaid because his physical address was listed a state away. We couldn’t get the best insurance money can purchase because he had a pre-existing condition. Our son was still in a very fragile state, with double vision, horrible stomach pains, crawling skin sensations, major sleep deprivation and continuous hot/cold sweats. He needed help — fast.

With no other viable options, our attorney managed to get an emergency stipulation granting my husband permission to drive our son the 2,600 miles across country to where we live. Meanwhile, I had stayed at our home, spending countless hours investigating insurance options and trying to find a residential treatment center for our son. My husband drove as he never had in his life, making the trip in three and a half days. They arrived in the middle of the night, our son a mere shell of the vibrant, funny, creative, loving soul that he once was.

We signed our son up for Medicaid in our state, which featured a 45-day backlog. We could request emergency consideration, with the possibility of them meeting us within 48 hours, but there was no guarantee. Our son would have to be assessed, and then there was the issue of actually finding him a bed at a residential treatment facility.

I must have contacted at least 25 treatment centers; none would take Medicaid. So there our son languished. We watched him slipping away from us as he struggled with his new sobriety and no treatment. If our son had been suffering from any other “acceptable disease,” waiting to obtain treatment would have been deemed unconscionable and cruel. From my view, it is beyond words that we ask those who suffer to simply bear their pain and deal with it.

I emboldened myself to share the situation with some trusted co-workers. The disease of addiction is still fraught with stigma, but I was so beyond that now, knowing that if we didn’t find something soon, the agony our son was experiencing would lead him to the streets. Human beings can withstand only so much pain. He was attending 12-step meetings as best he could but was so weak, it was hard for him to focus. He was more than ready for treatment and begged us to help him find something. He was simply too ill to do this on his own.

Through the grace of a co-worker, I was able to contact a treatment center that a relative of hers had attended with great success. I called, and we made an appointment the next day. The center took only private insurance, but we had already explored every other possibility. There were no other viable alternatives. It caused us to ponder, what does a person do who has no access to health care? (And, thus, all the overdose headlines!) We brought our son in for an intake assessment, and three hours later, he was in detox treatment; the timetable was for 35 days.

 

 

An equal-opportunity disease

Our story is merely a reflection of the countless individuals now suffering from our nation’s opioid crisis. Tragically, a huge percentage of those addicted are not so lucky as our son has been to have survived. Our son has an unfathomable journey ahead of him to maintain his sobriety. The shattering statistics confirm that only about 10 percent of individuals who are addicted find treatment — perhaps half of them will remain sober.

Our son’s addiction to opioids started as many others have. He had a back injury at work a few years ago, and his doctor prescribed OxyContin. Our son found some relief from the back pain but, more insidiously, found that it also helped with his longtime struggle with depression. Alas, he was a sitting duck. When the pills were gone, he tried to get more from the doctor, to no avail. He finally asked a friend, who led him to someone who had a few, and the rest is history.

On the streets today, one pill of OxyContin can cost as much as $60; a bag of heroin costs $5. There is no mystery why so many turn to heroin — not to get high but rather to relieve the impossible, all-consuming withdrawal. My son told us he tried countless times to overcome “the beast” on his own. The longest he made it was two and a half days — two and a half days of wretched, skin-crawling, vomiting, horrible agony. And we wonder why so many people are addicted. We treat people like criminals just for self-medicating their pain. We seldom think of them as even being human anymore, deserving of immense care.

As I tell my counseling students all the time, addiction is an equal-opportunity disease. I’m not a person in recovery, but I have attended dozens of 12-step, self-help meetings through the years. I worked as the program director of an outpatient substance abuse clinic for 10 years, often accompanying colleagues to open meetings so that I could honestly recommend them to my clients, know what they were all about and for the knowledge of “keeping it real” (that last one is crucial to me as a counselor and an educator.)

When I teach addiction courses, I ask my students to attend at least two open 12-step meetings if they are not seeking their own recovery but are there to learn, or two closed meetings if they are there to help themselves. They come back to class and share their experiences, which are often incredibly humbling to hear. They include tales of feeling embarrassed, finding it hard to enter the buildings, driving around several times looking for the courage to go in and acquiring sincere admiration and respect for those in recovery who have survived and share their journeys with others. The textbooks we have are tremendous, but nothing replaces the personal epiphany one can attain by witnessing these 12-step meetings. Many students have shared the sentiment, “There but for the grace of God …”

 

Holding on to hope

My irrational side tells me to beat myself up. I have been blessed with all this incredible knowledge and insight as a counselor and still did not know what my son was going through? I have refused to do so, however, not only because I realize that now is not the time for recriminations, but because I fully comprehend that addiction is a baffling and cunning disease.

It all makes sense now, of course — the endless need for money to pay for mysterious car breakdowns and vet bills for the dog, the many trips to see doctors for a once very healthy and fit young man, the horrible pain he was experiencing when his marriage fell apart. We wondered, of course, but were too far away to verify. We spoke frequently with our son but saw him briefly only three times over the past three years. Meanwhile, his addiction truly began to escalate.

It does no good to wallow in self-pity. It is just as futile to assign blame and fault. Pain, hurt, anger, frustration, desperation, sorrow, fear — all of these, and so much more, are ongoing and understandable. However, the one thing this disease cannot take from us is hope. The rational side of my being knows about evidence-based treatments, what has the best outcomes for success and what needs to happen.

In that sense, it has made things much easier for our family to endure because all of what is unraveling is in the range of “normal,” and that brings great solace. Our family is attending family counseling, going to Al-Anon meetings, reaching out to trusted friends and relatives, and realizing that we are so incredibly not alone. Still, it amazes me that if we were to tell a friend that our son has cancer, heart disease or even HIV, the response would be more understanding, more forgiving, more helpful. We have come light years in the field of addictions during the past two decades (I know — I teach this stuff!), yet we remain in the Stone Age as far as acceptance, understanding, scorn, victimization, blame and judgment go.

My hope is that readers will find some comfort in this writing (counselors are human beings first, with real-life crises of their own). I have found that addiction is an immensely alienating and isolating disease. So many people believe it will not happen to them or their loved ones because, after all, the person does decide on their own to pick up that first drink or drug, right? However, no one ever sets out in life to become an addict of any kind.

As human beings, our physiological needs are the most basic and supersede all others (refer to Abraham Maslow’s hierarchy of needs). We want relief from our physical/psychological/spiritual pain now and resort to self-medicating on a regular basis. I often ask my students, “What is your drug of choice? Is it caffeine, tobacco products, shopping, gambling, exercise, relationships, etc., etc., etc.?”

The point is, we are all slaves to our prefrontal cortexes, and once we find something that works for us, we make those lovely endorphins, the “intermittent positive reward” phenomenon takes hold, and we get positively rewarded for repeating that behavior. We are masters at conning ourselves into believing that the consequences of whatever we rely on continue to be far less than the rewards. And slowly, insidiously, the disease of addiction takes on a life of its own for far too many.

 

A time to take action

We know the physiology behind addiction. Those of us in the field screamed our warnings regarding OxyContin when it was first introduced in the late nineties. It didn’t require a huge knowledge of biochemistry to recognize the effects; its victims were immediately seen and affected so devastatingly.

Addiction professionals continue to scream from the highest pinnacles about the high potentiation for addiction from these drugs; we portended this epidemic well over a decade ago. And yet, here we are, still screaming of the dangers even as countless individuals are prescribed these drugs daily.

In 2017, the Centers for Disease Control and Prevention estimated that more than 115 people die every day due to opioid overdoses. I am not blaming the pharmaceutical companies (though perhaps I should?) or the physicians. Their ultimate goal (one hopes) is to adhere to the Hippocratic oath, to do no harm and to relieve human suffering. However, I believe that we have reached a tipping point, as Malcom Gladwell described in his book of the same name. Our nation is realizing that this crisis affects our mothers, our fathers, our sisters, our brothers, our daughters, our sons, our relatives, our friends, our co-workers, our ministers, our doctors … and ourselves.

The #MeToo movement has shown us the time for action is now. The #TimesUp movement is doing the same. The #NeverAgain movement is gaining immense momentum. It is time for our passions, our sensibilities and our combined courage to demand more research and increased access to treatment. It is time to get over our fear, ignorance and blame regarding addiction. And we need, once and for all, to acknowledge that the disease of addiction is happening at lightning speed all around us, with no letup in sight.

There is no time to waste on blame or recriminations; we need to act. Addiction can take hold of any of us, regardless of our training, our background, our socioeconomic status or our rationale. It happened to my son, despite all of the knowledge I possess as a counselor.

My fervent belief is that with understanding and proper intervention and treatment, we can more readily help those who are afflicted. More importantly, I believe we need to get at the real root of why people need to self-medicate in such powerful ways. We knew our son had problems with depression. He attended a few counseling sessions over the years, but there was no incentive to stay, and even taking the step of seeing a counselor came with perceived stigma. We all have the power to change the paradigms around this.

As of this writing, our son is more than 60 days clean and counting. He has completed his residential treatment and is living with us, taking it one day at a time and trying to deal with life on life’s terms. The neglect of his overall health has taken a huge toll, but together, we are trying to slowly repair its ill effects. This will definitely take time, but the joy is that now we do have that precious commodity.

My message to all my dear counselor colleagues is this: This disease affects all of us. The palpable pain of our nation is excruciating, and we are all awash in its collective anguish. As a nation, we must reach out, not suffer alone. We need to find hope, discover solace and all begin to heal. We also must find the profound courage to act and change our national discourse and paradigms on how we view and treat people who are self-medicating in hopes of finding relief from traumatic pain.

As counselor change agents, we can do this! There can be no higher calling. #EndOpiods.

 

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Antoinette D’Angelo is the pseudonym for an assistant professor of counselor education teaching in a university in the western U.S. She is a licensed mental health counselor, national certified counselor, master addiction counselor and licensed addiction counselor. She has worked in the human services/counseling profession for over 44 years. Her research interests include substance abuse and trauma treatment; crisis and disaster counseling; counselor wellness and alternative holistic treatment methods; and immigration, DACA, and refugee assimilation and reform.

 

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